CHC Impact Eval 2013

January 2013

Impact Evaluation

7501 Wisconsin Avenue, 1100WBethesda, MD 20814

www.nachc.com

Founded in 1995 by the National Association of Community Health Centers, Community HealthCorps is the largest health-focused, national AmeriCorps program

that promotes health care for America’s underserved, while developing tomorrow’s health care workforce.

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I. Executive Summary 5

II. Introduction 8

III. Description of the Community HealthCorps Program 10Mission, Vision, Beliefs 10Major Funding and Managing Partners 12Community HealthCorps’ Program Structure 13Program Theory and Logic Models 14Long-term Impacts: Economic Impact of Health Care 17

IV. Impact Evaluation Methodology 18

V. Findings by Key Program Component 20Community HealthCorps Central Administration and Leadership 20Community HealthCorps Operating and Service Delivery Sites 21Members 25Member Individual Outcomes 31Member-related Client and Community Outcomes 38

VI. Summary Findings and Recommendations 41

VII. Evaluation Process Findings and Recommendations 45

VIII. References 46

Table of Contents

Community HealthCorps . Impact Evaluation . National Association of Community Health Centers

HealthCorps members from East Boston learn about a migrant labor force at Suffolk Downs and see their living and working conditions first hand.

Like many migrant labor forces there is little in the way of benefits and protections afforded through laws.

Vacation or sick time is unheard of and a day not worked will equal a day not paid.

Therefore, it can be challenging for the workers to leave the track for medical care or other services.

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I. Executive Summary

Introduction

Cedarloch Research LLC was recently contracted to conduct an Impact Evaluation of the National Association of Community Health Centers, Community HealthCorps program. The research team utilized both qualitative and quantitative program data from the 2011-2012 program year (the second year of a three-year funding cycle). Findings from recently published empirical research served as comparison criteria for programmatic findings. The team also examined the existing evaluation processes to restructure an evaluation plan that would create a blueprint for capturing and storing the data needed for program improvement and to demonstrate program outcomes and impacts.

The ultimate purpose of the impact evaluation was to assess the extent to which the economic wellbeing of uninsured and underinsured individuals is predicted to change as a result of enrollment in health insurance and/or participation in health-related programs. The context for change were the activities of 481 Community HealthCorps participants (Members) working with 36 community health care providers (community health centers, primary care associations, or clinic consortia) in almost 200 delivery sites across 18 states, Washington DC and Puerto Rico. Services are provided in urban and suburban, rural and frontier areas to migrant farm workers, the uninsured, the underinsured, and homeless individuals.

“I can’t imagine anything I’d rather do than a year in HealthCorps.

Serving at this [agency]…is an opportunity that only AmeriCorps could provide.”


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Three evaluation objectives guided the evaluation process and the development of findings and recommendations.

1. Determine what recent empirical research studies show regarding each of the following:

a. To what extent are each of the following variables related to the others within “at risk” populations: a) access to community health care services, b) the extent to which individuals have health insurance, c) their levels of participation in community health care for health education and preventative services, d) their levels of participation in community health care services for acute and chronic health conditions, e) their current and predicted health conditions and those of their families, e) the socio-economic well-being of those individuals and their families, and f) the socio-economic wellbeing of their communities?

b. What are the key characteristics of community health care programs that maximize client access, enrollment, and continued use of health care services and insurance through the use of resources such as national and community service participants and volunteers?

c. What are the characteristics of national and community service participants and their work sites, activities and experiences during service?

d. What are the benefits to individuals, both personally and professionally, when involved in national and community service?

e. To what extent do individuals who have participated in national and community service programs ultimately contribute to professions and sectors, their communities, and society?

2. Determine what the 2011-2012 Community HealthCorps program data show regarding 1.b-e above.

3. Determine how 2011-2012 programmatic data compare and contrast to the empirical research results for 1.b-e above.

Methodology

The evaluation employed a causal-comparative (ex post facto) research design. The program’s theory of action served as the framework for identifying key independent and dependent variables. Additional independent and extraneous variables, identified through qualitative data analyses and the literature review, were also included in the final quantitative data analysis.

Thirteen different data sets were used in the development of a Member-level database. Various quantitative analyses were performed to determine and test new scales. Measures of internal consistency for new scales were determined using a Cronbach’s Alpha procedure.

Results

The Community HealthCorps program is achieving positive outcomes with the individuals that participate as AmeriCorps members. Results showed high levels of satisfaction with experiences and training, a gain in four different knowledge and skills sets as a result of experiences as a Member, more positive attitudes toward individuals with different backgrounds, and increased intentions to pursue a health-related profession and/or education. A number of areas for improvement were identified through the evaluation.

Results of recent empirical research supported the program’s theory of community change through: 1) the utilization of national service members as resources 2) in community health care settings, 3) increasing the amount and types of services that, 4) enhance access for potential/actual clients, 5) improving an individual’s health-related attitudes, knowledge, skills, intentions, and health-related choices, 6) improving individual health, 7) improving individual and family-related socio-economic circumstances, 8) improving community social and economic conditions.


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Recommendations for Program Design

The evaluation discovered a number of areas for improvement that will strengthen the program should be addressed in the coming program cycle. In order of prioritization, they included:

Redesign the Sub-grantee Risk Assessment Process and Instrument

Create an on-going, formalized system for Member feedback

Conduct a thorough evaluation of Prescriptions for Success core courses

Select models for Site Supervisor-Member relationship; provide training and resources for implementation

Examine and compare program implementation and management through the lens of successful decentralized models for volunteer programs

Explore what types of experiences provide Members the opportunity to develop and hone their skills related to professional behavior and appreciating diversity

Recommendations for Program Evaluation

Gather and use client information including demographic and participation data, perceptions, knowledge and skills, behavior choices, and actual health condition

Construct a separate database for program evaluation data that can be used in both formative and summative evaluation processes

Gather and analyze data that examine the interrelationships of Community HealthCorps Member as both beneficiary and benefactor of community health care

Future evaluations should be stakeholder-based, and employ a collaborative approach to design, implementation, monitoring and utilization of results

AltaMed Roosevelt High School Mural Dancing. AmeriCorps Week event where AltaMed hosted a school beautification day at the Roosevelt High School Academy of Medical and Health Sciences. They recruited over 100 volunteers from all over the health community and mentored the students interested in health careers while giving the school and it’s garden a makeover!


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II. IntroductionThis document contains the Impact Evaluation report for the National Association of Community Health Centers, Community HealthCorps Program. Cedarloch Research LLC was engaged to conduct the evaluation December 2012 - January 2013 using the data from the second year (2011-2012) of the three-year funding period for the current grant cycle (2010-2013).

The report is organized into the following sections: a) description of the program, b) methodology used to conduct the impact evaluation, c) findings by key program component, d) major findings, discussion, and recommendations, and e) key evaluation process findings and recommendations for redesign of the evaluation going forward.

Cedarloch Research LLC

Cedarloch Research LLC is a national social science research and evaluation firm serving public, private, and non-profit organizations that provide education, outreach, and social services to youth and adults. Clients include federal, state, and local governments, colleges and universities, Pre K-12 education systems, schools, and collaborations, and community-based organizations. Cedarloch and its clients share the common bond of commitment to enhancing opportunities for members of those populations that are traditionally underserved.

A major emphasis for Cedarloch is building individual and organizational capacity for program and policy development, implementation and evaluation, and strategic and long-range planning (including environmental scanning, needs assessment, theory of action design, identification of appropriate strategies, outputs, outcomes and impact, and selection of indicators and suitable measurement tools).

Cedarloch staff design, facilitate, and conduct applied social science research, action research, survey design, and the design of organizational performance measurement, monitoring, and data management systems that produce consistent, reliable and valid data for decision-making and accountability. Specific techniques include qualitative and quantitative research methods and data analysis, popular and scholarly literature review, development of program theory and logic models, surveys and focus groups, action research roundtables, community scans, prototyping, pilot testing, instrument development and validation, stakeholder capacity-building, and expert panel assessment and review.


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Although the focus for many clients is improving public literacy and action related to a specific discipline, Cedarloch offers research, program development and evaluation services to a variety of organizations desiring to improve their educational processes, public outreach, and engagement capacity.

Cedarloch Research LLC uses regularly accepted approaches and methods of social science research and evaluation. Researchers for this impact evaluation were Emma Norland, Jennifer Krabill, Cynthia Somers, and D. Michael Krabill.

Evaluation Purpose and Objectives

The purpose of the impact evaluation was to assess the extent to which the economic wellbeing of uninsured and underinsured individuals is predicted to change as a result of enrollment in health insurance and/or participation in health-related programs. The context for change is the effort of 481 Community HealthCorps Members working with 36 partner organizations (community health centers, primary care associations, clinic consortia) in almost 200 delivery sites across 18 states, Washington DC and Puerto Rico. Services are provided in urban and rural areas to migrant farm workers, the uninsured, the underinsured, and homeless individuals.

In order to understand the nature of the program and its current and potential impact, the following objectives guided the evaluation:

1. Determine what recent empirical research studies show regarding each of the following:

a. To what extent are each of the following variables related to the others within “at risk” populations: a) access to community health care services, b) the extent to which individuals have health insurance, c) their levels of participation in community health care for health education and preventative services, d) their levels of participation in community health care services for acute and chronic health conditions, e) their current and predicted health conditions and those of their families, e) the socio-economic well-being of those individuals and their families, and f) the socio-economic wellbeing of their communities?

b. What are the key characteristics of

community health care programs that maximize client access, enrollment, and continued use of health care services and insurance through the use of resources such as national and community service participants and volunteers?

c. What are the characteristics of national and community service participants and their work sites, activities and experiences during service?

d. What are the benefits to individuals, both personally and professionally, when involved in national and community service?

e. To what extent do individuals who have participated in national and community service programs ultimately contribute to professions and sectors, their communities, and society?

2. Determine what the 2011-2012 Community HealthCorps program data show regarding 1.b-e above.

3. Determine how 2011-2012 programmatic data compare and contrast to the empirical research results for 1.b-e above.

Impact evaluation typically answers the question, “what would have been the conditions of the target population(s) in the absence of the program?” Impact evaluation is either evidence-based or evidence-informed. For evidence-based evaluations, an experimental design is preferred.

For evidence-informed studies, triangulation of methods, data sources, and use of a quasi-experimental research design, if possible, are acceptable and produce credible and usable data for decision-making. Criteria for program success for impact evaluations can be identified from: conditions and results of comparison programs including the program itself, conditions existing where there is not nor has been a similar program, conditions and outcomes for a ‘best-in-class’ program, from recently published empirical research, or a combination of these.

This evaluation used recent empirical research results as criteria for judging the program, predicting impact, and making recommendations for changes to the program and its evaluation.

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III. Description of the Community HealthCorps Program

Introduction

This section contains an overview of the Community HealthCorps program including the mission, vision, beliefs; major funding and managing partners; Community HealthCorps program structure; program theory and logic models; and long-term impact.

The program’s major funding and managing partners include the Corporation for National and Community Service, the National Association of Community Health Centers, and the set of sub-grantee Operating Sites consisting of local community health organizations and their service delivery sites.

Mission, vision, Beliefs

Founded in 1995 by the National Association of Community Health Centers, Community HealthCorps (CHC) is the largest health-focused, national AmeriCorps program that promotes health care for America’s underserved, while developing tomorrow’s healthcare workforce.

Community HealthCorps members (through AmeriCorps) perform a variety of activities associated with health services and programs for patients and community, often by functioning as community health workers (CHWs).

Over 1,200 Community, »Migrant, Homeless, and Public Housing Health Center organizations, providing care through more than 9,000 service delivery locations.48%of health centers »organizations are rural.Health centers employ »153,000 individuals (FTEs).Health centers currently »provide 88.3 million patient visits annually.

Nearly 22.3 million patients currently served, of whom:

36.4% are uninsured »39.3% have Medicaid/SCHIP »7.8% have Medicare »14.1% have private insurance »2.4% have other public »insurance coverage (including non-Medicaid expanded SCHIP)1.1% of kids enrolled in SCHIP »71.8% are below poverty »92.5% are low income (below »200% of poverty)

Health centers serve large numbers of the nation’s most vulnerable, including:

1 in 7 Medicaid beneficiaries »1 in 7 uninsured persons »1 in 5 low income, uninsured »persons1 in 3 individuals below »poverty1 in 3 minority individuals »below poverty1 in 3 children below poverty »1 in 7 rural Americans »Almost1 million migrant »farmworkers1.2 million homeless persons »

Sources: NACHC, January 2013. Based on 2011 Uniform Data System (to which all federally funded health centers must report), estimates from survey data of non-federally funded health centers (health center “look alikes”), estimates for annual patient growth, and national data sources.

naCHC by the numbers(Numbers on Health Centers and Patients, as of January 2013)

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Community HealthCorps members serve rural, urban and suburban communities, as well as migrant farm worker, homeless and public housing populations.

Figure 1 - Community HealthCorps’ Operating Sites

www.communityhealthcorps.org

www.facebook.com/communityhealthcorps www.twitter.com/commhealthcorps


Promoting Health Care for America’s Underserved

Developing Tomorrow’s Health Care Workforce

What is Community HealthCorps?

Founded in 1995 by the National Association of Community Health Centers, Community HealthCorps is the largest health-focused, national AmeriCorps program that promotes health care for America’s underserved, while developing tomorrow’s health care workforce. The mission is to improve health care access and enhance workforce development through community health center sponsored AmeriCorps including VISTA (Volunteers in Service to America), and related programs. Overarching goals to address the needs of medically underserved and other vulnerable populations served by community health centers are as follows: Increase access to and utilization of primary and preventive health care. Improve the capacity of health centers to provide quality and preventive primary health care services. Foster collaborative partnerships that ensure continuity and sustainability of programs and services. Encourage Community HealthCorps Members to pursue further education and careers in community health

through mentorship and experiential learning. Create a culture of civic engagement and volunteerism to strengthen preventive and primary health care. Community HealthCorps program sponsors are primarily community health centers (CHCs) and primary care associations (PCAs) that host one or more teams of HealthCorps Members. Operating since 2001, Community HealthCorps*VISTA is comprised of project stations (sponsors) - predominantly CHCs, PCAs and hospitals that typically host one or two VISTA Members. Most Members enroll for a full year of service, and many serve for two terms of service. Nearly 500 Community HealthCorps Members currently serve through 35 main health center sites (which include over 350 individual member placement sites) and three affiliate organizations in 18 states, the District of Columbia and Puerto Rico. Members Reflect and Work in Underserved Communities

Members serve rural and racially/culturally diverse urban communities and suburban, as well as migrant farm worker, homeless and public housing populations. Members are as racially, ethnically and economically diverse as the communities they serve. Educational attainment varies from high school and some college to graduate degrees. In addition, some Members are active or retired health and social service professionals. No matter their background, Members become part of a community’s struggle for better health and economic independence.

Mission

...to improve health care access and enhance workforce development for community health centers through national service programs.

Vision

...to become a national service pipeline for careers in community health centers that is improving access to necessary primary and preventative care services for the medically underserved.

Beliefs

Community HealthCorps is an asset to communities by bridging healthcare & national service.

The power of Community HealthCorps provides the tools & resources to impact the lives of many.

Community HealthCorps is a stepping stone to a brighter future not only for the individual who serves, but to the communities they serve.

Community HealthCorps provides a continuous avenue of professional development & personal growth.

In AdditionCommunity HealthCorps members serve •as “Agents of Change” in preventive and primary care services. They provide a variety of evidence-based health services and programs for patients and communities, primarily through community health centers.

The roles of Community HealthCorps •members are diverse, complement the communities they serve, and seek to lift barriers that medically underserved people experience in accessing healthcare.

Approximately 1.2 million people who lacked •access and inadequately used available health services and programs benefited in 2009-10 from the service activity of Community HealthCorps members (AmeriCorps national service volunteers).

In 2009-10, 159,932 people used preventive •and primary healthcare services and programs two or more times within the program year.

Community HealthCorps members help •build the capacity of community health centers, health center networks and other organizations to recruit and utilize community volunteers. They help mobilize and support volunteerism in one-time and ongoing activities that address community and health center needs.

In program year 2010-11, the Community •HealthCorps program has provided services to approximately 594,029 people at more than 150 delivery sites across 19 states, the District of Columbia, and Puerto Rico, who lacked access and inadequately used available health services and programs.

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Major Funding and Managing Partners

The Corporation for National and Community Service

The Corporation for National and Community Service (CNCS) is a federal agency that engages more than 4 million Americans in service through Senior Corps, AmeriCorps, and the Social Innovation Fund, and leads President Obama’s national call to service initiative, United We Serve.

Each year, more than 4 million individuals of all ages and backgrounds help meet local needs through a wide array of service opportunities. These include projects in six priority areas: disaster services, economic opportunity, education, environmental stewardship, healthy futures, and veterans and military families through CNCS’s core programs: AmeriCorps, Senior Corps, and the Social Innovation Fund (http://www.nationalservice.gov/about/overview/index.asp).

CNCS is the primary funding partner of Community

HealthCorps as an AmeriCorps program. During the 2010-2013 program cycle, CNCS awarded $5 M in funding to the National Association of Community Health Centers to manage and implement the Community HealthCorps program.

The National Association of Community Health Centers

To address the widespread lack of access to basic health care, Community Health Centers serve over 22 million people at more than 9,000 sites located throughout all 50 states and U.S. territories.

Health centers depend in large part on public financial help and need a unified voice and common source for research, information, training and advocacy.

To address these needs, the National Association of Community Health Centers (NACHC) organized in 1971. NACHC works with a network of state health center and primary care organizations to serve health centers in a variety of ways:

Provide research-based advocacy for health •centers and their clients.

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Educate the public about the mission and •value of health centers.

Train and provide technical assistance to •health center staff and boards.

Develop alliances with private partners and •key stakeholders to foster the delivery of primary health care services to communities in need.

In the NACHC family, Community Health Centers serve the primary health care needs of more than 22 million patients in over 9,000 locations across the United States. Health centers play a crucial role during tough economic times, providing affordable health services for millions of uninsured and newly jobless Americans. Health centers provide a unique and comprehensive approach to health care that saves money, improves patient health, and creates good local jobs in the communities that they serve.

Community Health Centers save money every time an uninsured patient opts for an exam and treatment at the first sign of a health issue instead of waiting until a costly Emergency Room visit is the only option. Health centers also save money for Americans looking for work whose families could otherwise face poor health without care, or piles of medical debt.

Each health center takes a unique approach to meet the needs of the people in the surrounding community. That local approach to health care, combined with an innovative emphasis on comprehensive preventative care, generates $24 billion in annual savings to the health care system – to taxpayers and private payers alike.

Community HealthCorps’ Program Structure

Using funding from CNCS to create the Community HealthCorps program, NACHC envisioned a way to expand its reach and impact by utilizing the human capital provided by AmeriCorps members. Through a competitive process, NACHC passes most of the money it receives from CNCS through Community HealthCorps to Sub-Grantees (mostly federally approved health centers and Primary Care Associations) located throughout the United States. The Sub-Grantees place AmeriaCorps members (called Navigators) at select outreach sites where they directly assist the facility and engage with underserved audiences in health-related services.

Figure 2 - Program Structure Model

NACHC

Operating Site

Comm

unity

HealthCorps

Delivery Site

CNCS

Operating Site

Operating Site

Operating SiteOperating

Site

Delivery Site

Delivery Site

Delivery Site Delivery

Site Delivery Site

Delivery Site

Delivery Site

Delivery Site

Member

MemberMember

Member

Member

Member

Member

Member

Member

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Program theory and logic Models

A program’s theory describes the assumptions made about resources, activities, and outputs and how they lead (or will lead) to intended outcomes. (44) In addition to the description of the program’s theory, most programs typically have logic models to graphically represent program theory.

Program logic models are brief diagrams that give a picture of how the program theoretically works to achieve benefits for participants. They clarify the cause-and-effect relationship among program resources, activities, outputs, and outcomes from key stakeholder perspectives. (43) Most formative and summative evaluations rely on program theory as articulated in logic models to identify evaluation questions, associated metrics, and types of analyses.

A program’s theory of action can be developed before the program is implemented or after the program is under way. (45) For the Community HealthCorps, the basic program theory has been used for program design, evaluation, monitoring, reporting, and redesign across the life of the program.

Below is the basic logic model illustrating the theory of the Community HealthCorps as it relates to client health and community well being. The national service component of this logic model (the Community HealthCorps and Members) is a critical divergence from traditional health care approaches for underserved populations and meshes well with an overall philosophy of community health care.

Figure 3 - Basic Logic Model

Inputs

Community HealthCorps• Services• Type• Americorps component• Staff• Center• Risk assess

Members• Demographics• Assignments• Background• Training• Length of participation• Supervision• Post-participation plans

CHC Central• Cohesive vision• Leadership• Accountability, monitoring• Training, facilitation• Accommodations, flexible

Medical Care

Education

Support Services

Education

ActivitiesClient

Activities & Outputs

Short-Term Outcomes

Intermediate Outcomes

Long-Term Outcomes

COMMUNITY IMPACT

Program Coordinator

Supervision

Direct Service• Recruit volunteers• Training• Fundraising• Lunch

Medical Health

Knowledge

Attitude

Skills

Plan to change

Change in health behavior

Family well-being

Financial impacts

Social impacts

Community changes

Economic impact

Service

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The program logic model has highlighted three major inputs: the local community health center, the Member, and national program administration. Each of these inputs has important characteristics and elements that work in concert to develop and support a community health care system that incorporates national and community service as a critical component for maximizing access to basic health care while serving as a workforce education laboratory for its future leaders.

The streams of program activities converge at multiple points throughout the Member’s year of service as well as along a client’s interaction with the health care system. Local community health centers and their delivery sites (sub-grantees) guide Members in their experiences; the program’s central administration supports the sub-grantees’ and Members’ activities; the Members guide clients through health care and associated services and

systems. These activity and participation streams mirror each other, creating the opportunity for mutual learning experiences and prospects for success for both target audiences for the program (Members and community health care clients).

The figure below examines the elements most likely to affect a Member’s experience and hypothesized outcomes. Both of these logic models contributed to the selection of variables to include in the evaluation.

Figure 4 - Member Logic Model

Health Professional

Personal GrowthCommitment to Service

Operating & Delivery Sites

Training

Member

Delivery Site Supervisor

Direct Service

Client Interaction

Peer Interaction

CHC


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Community HealthCorps . Impact Evaluation . National Association of Community Health CentersCHERRy STREET

Relieving the Burden on the Healthcare System: Cherry Street Health Services

The Challenge

Nationwide, 43.6 million people live below the poverty line. Most live without health services because they cannot afford them or do not realize that they may qualify for children’s health insurance, Medicare, or Medicaid. Instead they often wait until they get sick and seek medical attention in emergency rooms.

Emergency rooms are designed to manage emergency medical issues. When they become a last-minute alternative for those who avoid preventative care, the system becomes overburdened and loses its effectiveness for emergency medical conditions. It is imperative to keep the underserved from relying on emergency rooms. This can improve the health of millions of people and keep the healthcare system.

Service: An Integrated Component of the National Healthcare System

The National Association of Community Health Centers founded the Community HealthCorps AmeriCorps program to promote healthcare for America’s underserved while developing tomorrow’s healthcare workforce. Community HealthCorps members work as community health workers. They supplement the work of medical professionals by helping patients with information about prevention and maintenance of social conditions. They also run awareness campaigns and help people sign up for Medicare and Medicaid.

Service at Work: About Michigan Cherry Street Health Services

Cherry Street Health Services of Grand Rapids, MI, employs Community HealthCorps members

as service providers, while providing them with a workforce development opportunity. Community HealthCorps members inform patients about preventative care, maintenance of chronic health issues, and other services available to them. Approximately 10% of Cherry Street’s full-time staff originated from its Community HealthCorps members.

Smart Money

Cherry Street Health Services leverages AmeriCorps funds by providing funds through its board of directors.

Conclusion

Michigan Cherry Street Health Services provides value at two levels:

It provides a cost-effective way of keeping •thousands of people out of the ER per year

It contributes to the overall growth of the •healthcare industry in the state by providing jobs and training for entry level positions in the field.

Source: Excerpts from the report “Doing More with Less - Case Studies on the Impact of National Service” (2011). RootCause.


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long-term impacts: Economic impact of Health Care

The long-term impacts of the Community HealthCorps program and thus the articulated needs for its continuance relate to: 1) the individual participating in a national service program as a Member, and 2) the community in which the Member serves. The context for community change is expanded access for uninsured and underinsured populations to community health care and the relationship of this access to the social and economic wellbeing of individuals and their communities. To what extent does the social and economic well being of individuals and communities improve as a result of uninsured and underinsured populations enrolling in health insurance and/or participation in health-related programs? The following is a brief discussion of this logic.

Access to health care is closely related to having health insurance. Those individuals with health insurance generally have easier access to health care. Individuals that lack health insurance tend to be in poorer health and die earlier than those with insurance. (11, 18) Individuals with insurance are more likely to have a primary doctor, proper prescription medications and less reliance on emergency care. (12- 16, 18) Individuals with insurance are more likely to have chronic illnesses under control by regular visits to their primary care physician and a regimen of medication, whereas those without insurance report the opposite. (14, 16)

The economic impact of having health insurance on an individual’s finances can vary depending on the type of health care sought. (23-26) For example, health insurance may not have as big of an impact on individuals that suffer a health shock or unexpected emergency. (25) However, research shows that the economic impact felt by those with long-term chronic illnesses in need of continued management of medication regimes and preventative care can vary substantially dependent upon health insurance coverage. (25)

The lack of insurance affects family stability when there is a consistent worry regarding potential significant financial consequences of a health crisis. (11)

Many communities with high rates of uninsured individuals face the risk of losing health care capacity. High rates of uninsured can often result in hospitals providing more limited services or other health providers leaving the area due to financial instability. (11)

The lack of health insurance places an economic burden on the individual, his or her community and society as a whole. (23-25, 28) The federal government spends an estimated $25 billion per year to finance health care for those individuals that lack insurance coverage. (24) “$65 to $130 billion can be gained in better health outcomes each year if there is continuous health care” for all individuals in the U.S. (11)

Increased access for the uninsured and underinsured through Community Health Care is a strategy that addresses individual, family, and community concerns. Utilizing a national service program such as the Community HealthCorps to maximize capacity and enhance success of community health care systems to provide access has been successful in the past. (9)

One of the largest issues facing community health care providers has been the ability to reach those populations most “at risk” and encourage utilization of the health care system and other benefits that may be available to them. When community health care systems are successful at delivering cost-effective and efficient primary care to “at risk” populations, a number of cascading outcomes are realized: Emergency room visits decrease, hospitalizations also decrease and overall health outcomes improve. (2, 17, 21) These outcomes are estimated to save between 10 and 17 billion dollars a year. (2)

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IV. Impact Evaluation MethodologyIntroduction

This section contains a description of the data sources, sampling processes, instrumentation, and data collection and analysis methods used during the evaluation. The evaluation employed a mixed-methods approach with both qualitative and quantitative methods and data to maximize the explanatory value of a study limited by time yet seeking to examine program impact. The evaluation design intentionally involved dual paradigms, each offering a meaningful and legitimate way of knowing and understanding. (37, 38, 39)

As shown in the figure below, there were three major components to data collection and analysis: a) analysis and synthesis of recent empirical studies and other documents and publications, b) construction and analysis of a Member data base utilizing information gathered from multiple data bases from the 2011-2012 program year, and c) selection and further development of case studies taken from the top 25 great stories of the 2011-2012 Great Stories data base.

Figure 5 - Three Components to Data Collection

Program Data (Qualitative)

Empirical Research ResultsImpact

Evaluation of CHC

Program Data (Quantitative)

Three Components to Data Collection

3

2

1

In an evidence-informed study (and the resulting programmatic implications), the results from recent empirical research serve as the criteria to which the findings from a program’s evaluation are compared. Conclusions and recommendations emanate from those comparisons as well as any explanatory results within the program evaluation data. Triangulating quantitative and qualitative methods provided evaluation data that both described and explained why differences existed between the program’s implementation and outcomes and the criteria gleaned from recent empirical research.

The evaluation employed a causal-comparative (ex post facto) research design. The program’s theory of action served as the framework for identifying key independent and dependent variables. Additional independent and extraneous variables, identified through qualitative data analyses and the literature review, were also included in the final quantitative data analysis. The program’s theory of action, portrayed in a logic model, is presented in Section III of this report.

The evaluation used generally accepted practices for research methods, instrumentation, and data analysis. Scales developed from initial quantitative data analyses were tested for internal consistency using a Cronbach’s Alpha model with a target of (r= .7) or above.

Development of Case Studies and Analysis of Qualitative Data

Case studies were selected using a purposeful sampling process in order to maximize the depth, breadth, richness, and understanding of the phenomena in play in this complex program. As results emerged from the empirical literature and initial quantitative analyses, cases were selected from the Great Stories database that provided illustrative and explanatory value.

In addition to the data provided from specific case studies, the evaluation has relied on results from

“I’ve always had a strongsense of volunteerism.I knew that I would want to continue in service and take part in some type of public service program after college – the question was, where would I do it? Once I started taking note of the needs of the community around me, I knew it would only feel right to do public service in that same community. Community HealthCorps is allowing me to fulfill my life mission of volunteerism where it means the most.”

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an analysis of qualitative data residing in several of the data sets listed. The data sets providing the greatest number and most useful information were the Quarterly Program Coordinator Reports and responses to two items from the Member Exit Survey: “The best thing about Community HealthCorps is…” and “If I could change anything about Community HealthCorps…” Written comments from each of these were categorized, sorted, and then analyzed to identify underlying themes and related constructs. As results emerged from the empirical literature and initial quantitative analyses, quotes were selected from these data sets that provided illustrative and explanatory value.

Development of the Quantitative Database

Multiple data sets from the 2011-2012 program year were obtained from NACHC. Individual Members, Operating Sites, and service delivery sites were all given control numbers across data sets in order to establish a base level of confidentiality. At the end of the evaluation study, all contributing data sets were destroyed and the master database (developed in PASW as a ‘.sav’ file) was shared with NACHC for further analyses if desired and to serve as a potential model for data collection in future evaluations.

The following data sets were utilized in the development of the quantitative database and all data were transformed into Member level measures.

Community HealthCorps Program Directory•

Member Assignment•

Member Timesheet•

Member Exit Survey•

Operating Site Roster•

Service Site Roster•

Operating Site Program Coordinator Roster•

Member’s Site Supervisor Roster•

Member Direct Service Report•

Operating Site Risk Assessment•

Community HealthCorps Great Stories•

Operating Site Program Coordinator •Feedback

Member Individual and Team Training•

Creating Quantitative Scales

To determine alternative underlying factors affecting responses and/or to reduce the data to meaningful categories, exploratory factor analyses were conducted with responses from all Member Exit Surveys. Using Principal Components Analysis extraction with Varimax Rotation (with Kaiser Normalization), sets of items were combined to create sub-scales. During analysis, missing data were replaced with item means. Scores on each scale were calculated using the mean of the sum of the items contained in the scales. Results of the factor analyses are presented in the Findings section of this report.

Data Analysis for Quantitative Measures

The final database contained nominal, ordinal, and scale-level data for analysis. Appropriate descriptive statistics were employed to examine and summarize the data. Relational techniques including correlation and stepwise multiple regression were used to determine relationships among independent variables and between independent and dependent variables.

To compare groups, means and standard deviations were computed and examined across groups of interest. Because the data from the 2011-2012 program year were considered to be from a census of that year and the program year was not randomly selected, no inferences are made to a different or larger population (no inferential tests with probability levels). Practical significance is deemed more appropriate than statistical significance for this evaluation.

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V. Findings by Key Program ComponentIntroduction

This section contains the evaluation findings organized by key program component. Those components include: 1) Community HealthCorps Central Administration and Leadership, 2) Operating and Affiliated Service Delivery Sites, 3) Member, 4) Member Individual Outcomes, and 5) Member-related Client and Community Outcomes.

Each program component contains descriptive information, program-related qualitative and quantitative findings, and relevant literature citations.

Community HealthCorps Central administration and leadership

The central administration of Community HealthCorps is conducted by NACHC staff. There

are 11 staff members in the central Community HealthCorps office; five of which are AmeriCorps alumni. This team is responsible for administering the overall program as well as providing a cohesive vision to all the program’s partners (including the set of Operating Sites and their service delivery sites. Their duties include:

Administering the Community HealthCorps •program (developing and managing projects)

Organize a competitive application process •for choosing new Operating Sites

Helping to interpret AmeriCorps regulations, •providing technical assistance, and enforcing administrative policies and AmeriCorps regulations

Monitoring for compliance of Operating Sites•

Approving Member assignments•

An important task of the central office staff is the selection of program sites (sub-grantees). The timing of this process did not allow for it to be observed as part of this evaluation; however, the application materials and process were reviewed to determine the likelihood that they would result in highly qualified program applicants and sub-grantees.

The analysis revealed that the application process

Member Danielle Schroeder (Grace Hill Health Centers, Inc. in St.

Louis) hosted a Teen Awareness Health Fair. Danielle serves in the

Community Health department at Grace Hill in the Teen Initiative

program. The purpose of the program is to decrease a second

pregnancy to participants while in their teens that have a delivered

one child in their teen years.

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is detailed, clear, and specific in requirements and evaluation criteria. It clearly outlines that potential partners must demonstrate the following: a need for the program in the community they will serve; how Members are a highly effective means to address this need; how they will implement an evidence-based/informed approach which can demonstrate measurable impacts; a clear plan for recruiting, retaining, training and supervising Members; a description of the organizational structure and capacity for managing the program; and a clearly outlined, cost-effective and adequate budget.

In addition to the above requirements, programs must provide evidence of collaboration and not duplicate or compete with other programs in their respective community. Research suggests that competition between Health Centers for valuable resources should be discouraged in an effort to foster collaboration and cooperation between programs. (21) And community health care providers that work with other community-based service providers in a collaborative approach have higher success rates with client short-term and long-term health care and health-related results. (6, 7, 10, 17, 19, 23)

An emphasis on collaboration is highlighted during the proposal process. Applicants must define the lead sponsor agency, its responsibilities and the responsibilities of collaborating agencies, as well as the value they each bring to the program. Collaboration and community support must be demonstrated by the specific programmatic, administrative, and financial roles each partner will play.

National Program Coordination and Operating Site Staff Training

One of the services the central office provides to sub-grantees is Program Coordinator and Site Supervisor training and resources. Training addresses program administration, including monitoring and reporting requirements, as well as Member issues such as recruitment, development of service assignments (direct service, fundraising, and capacity building), training, and supervision. Also included in training is information regarding Community HealthCorps’ program performance measures which for the 2011-2012 year focused on delivery of health services (primary) along with reducing childhood obesity and volunteer generation (both secondary).

Program Coordinators value the training opportunities. One suggested: “It would be most useful for our program to have access to the NACHC-led Member trainings to view at any point in time that is convenient for the entire team. For example, we could show them at team meetings.” Many of the training resources are now available through the Community HealthCorps website.

Monitoring and Accountability

A variety of reporting systems are in place to monitor sub-grantees activities and outputs. These include the OnCorps Reports (a CNCS-compliant, web-based reporting system used by Members for timekeeping) as well as Quarterly Program Coordinator Reports and the end-of-year annual, Operating Site Risk Assessment. The evaluation examined the Risk Assessment data gathered from the 2011-2012 program year. Data are used to assess the ability of the sub-grantee to provide a successful experience for Members.

There are three sub-components to the Operating Site Risk Assessment: Staffing, Management, and Financial. The average risk scores were: Staffing (1.30 out of a possible 8, sd=1.08, n=393); Management (3.00 out of a possible 19, sd=2.12, n=393); Financial (.67 out of a possible 8, sd=.59, n=393); and Total (4.96 out of a possible 35, sd=2.63, n=393). The lower the score, the less risk indicated in the management of the program at the Operating Site.

Community HealthCorps operating and Service Delivery Sites

The Community HealthCorps program is implemented at a local level. As described in the previous section, program applicants propose how they will utilize Members to maximize health care access while providing them with the critical experiences needed to develop and grow professionally and personally.

The Community HealthCorps program utilizes a decentralized approach to program management (similar to a decentralized model for volunteerism) across all levels of the program. Even though

22

a more centralized model could enhance coordination among top-level agencies, would provide tighter control over scarce resources, and may contribute to a better match of volunteers to agency needs, a decentralized model “lends itself more to informality and creativity and permits rapid adjustments to changing or unexpected circumstances”. (33)

The hallmarks of a decentralized model are variation and independence that requires adaptability. Each project essentially operates as a freestanding entity without standardized central office oversight. (34)

For the Community HealthCorps, this model acknowledges the depth of knowledge and experiences the leaders at the local level have with their communities, their understanding of the nuances of the client base, and their familiarity with unique cultural and social issues. (22)

Organizations Participating in Community HealthCorps

Community HealthCorps has eligibility requirements for each organization applying for funding from the program. The program has three general categories of organizations that are eligible for funding (percentage of 2011-2012 sub-grantees for each specific type):

Federally qualified health centers and look-a-•likes (66%)

Primary Care Associations that will place the •individuals serving at member organizations serving health center populations (20%)

Health center controlled networks, •regional consortia, and other intermediary organizations that will place the individuals serving at member organizations serving health center populations (14%)

The sub-grantees (a total of 36 for the 2011-2012 program year) serve as a centralized source for identification, selection, and initial training of Members while Member activities actually occur and are supervised at a service-delivery or outreach site. This hybrid model establishes baseline expectations and ensures that results can be “rolled up” across sites. The assignment of duties at the service delivery site allows for flexibility and responsiveness to local needs and conditions. Successful leadership

at the delivery site level however, “should be open to program change and innovation”. (22)

Members are similar to volunteers in some ways and “volunteer sustainability is likely to rely heavily on social capital and a sense of volunteer community and respect”. (36) If service delivery sites (and thus Members) are separated by geography and/or type of client base/community issues, all levels of program management must work to engender the identity of each Member as belonging to one Community HealthCorps. (36)

There is a delicate balancing act for programs when planning Member activities. They work to create the team atmosphere locally while nurturing the affiliation with a national service organization and helping to build an identity as health care professionals. However, many Members have experiences at the local level that lead to longer-term results. One wrote, “Never have I had the privilege and opportunity to be part of a program that encourages collaborations and team building to reach a better/healthier community. It has nurtured and encouraged my curiosity in public health issues and has allowed me to further explore those curiosities and passions, and for that I am very grateful.”

Each Operating Site has one individual who serves as the Program Coordinator for the Community HealthCorps (description below). Because most Operating Sites have multiple service delivery sites (in 2011-2012, the number of delivery sites per sub-grantee ranged from one to 14), frequently the Program Coordinator is located many miles away from the day-to-day operations of sites, Site Supervisors, and the Members. For the 2011-2012 program year, the average number of miles a Program Coordinator traveled per service delivery site ranged from 0 miles to 148 miles.

When examining both the number of service delivery sites and the distance each site is from the sub-grantee location, there appears to be a group of sub-grantees whose Program Coordinators face a difficult task of managing a multi-site, geographically dispersed program.

23

Here are three examples from the data:

Figures 6,7,8 - Examples of Geographic Dispersion

Program Coordinator

Number of Delivery Sites

Number of Members

Closest Delivery Site

Farthest Delivery Site

A 11 21 0 miles 82 miles

B 7 16 0 miles 216 miles

C 9 14 0 miles 98 miles

“The people I have met through HealthCorps have been amazing.From my fellow HealthCorps members and Program Coordinator to my supervisor, patients and coworkers at my site, I have met incredible individuals who have inspired and supported me throughout this wonderful experience. My fellow HealthCorps members have become really great friends. We all share a common belief in public health and serving our community. My Program Coordinator is absolutely amazing. She doubles as my supervisor and I am so glad to have met her this year. She is supportive and understanding and has been a wonderful friend. Finally, my organization and patients have been life-changing. I have always wanted to pursue a career in medicine, but I have learned so much over this past year. I am currently applying to medical school with hope to someday work in an organization very similar to Boston Health Care for the Homeless. It is inspirational to work every day with coworkers to who believe in their mission to serve others. My patients are fantastic, and I hope to continue my career working with underserved populations.”

[Wei Sum Li, Member]

www.CommunityHealthCorps.org

Of those community members directly served...

Other areas of service activities included: Financial counseling and eligibility assistance Parenting education Health education and supportive counseling Physical education and healthy eating classes Housing and transportation assistance ...and more!

2011-12 Program Year For the next program year of 2011-12, twelve Community HealthCorps members will continue serving in Ohio, with almost 500 members serving nationwide. In the upcoming year, Community HealthCorps members will continue volunteering in racially/culturally diverse rural, urban and suburban communities, as well as migrant farm worker, homeless and public housing populations. No matter where they serve, Community HealthCorps members become part of a person’s struggle for better health and economic independence.

Where Members Serve in Ohio (2011-12 Program Year)

Case management including assessment, facilitation & referrals was provided to 1,894

Ohio Community HealthCorps members directly served

17,793 people during the 2010-11 program year.

698 were enrolled in health insurance,

prescription assistance

& other programs/services

613 received outreach services

Map created using G

oogle BatchG

eo

For more information, click this QR code using your smartphone or other

compatible device.

2011-12 Program Year For the next program year of 2011-12, almost 30 Community HealthCorps members continue serving in Connecticut, with almost 500 members serving nationwide. In the upcoming year, Community HealthCorps members will continue volunteering in racially/culturally diverse rural, urban and suburban communities, as well as migrant farm worker, homeless and public housing populations. No matter where they serve, Community HealthCorps members become part of a person’s struggle for better health and economic independence.

www.CommunityHealthCorps.org

Of those community members directly served...

Other areas of service activities included: Health education & supportive counseling Interpretation services Parenting education Employment referral & counseling Housing assistance

Volunteer management & children’s book

distribution through “Reach Out & Read” Physical education & healthy eating

classes ...and more!

“The best thing about Community HealthCorps was meeting my fellow teammates and learning

that I am going to make a great nurse.” – Shana (Community Health Center, Inc.)

Where Members Serve in Connecticut (2011-12 Program Year)

Map created using Google BatchGeo

2,251 were enrolled in health insurance,

prescription assistance & other programs/services

Connecticut Community HealthCorps members directly served

15,058 people during the 2010-11 program year.

2,869 were provided case management

services (referrals, facilitation

& assessments)

Outreach services were provided to

3,812

For more information, click this QR code using your smartphone or other

compatible device.

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The Role of the Program Coordinator

Community HealthCorps is designed to have at least one designated staff contact (the Program Coordinator) that is responsible for the leadership and coordination of the local Operating Site. These individuals are essential in the effective functioning of the Community HealthCorps program.

They are expected to attend monthly conference calls, an annual grantee meeting, provide timely reporting to NACHC, and monitor the day-to-day activities of their program overall. Research shows that the role of the Program Coordinator is crucial in interacting with volunteers and staff. Thus, these individuals should be familiar with how to retain and build a volunteer workforce as well as possess skills in overall program management.

Program Coordinators are responsible for training Site Supervisors before they interact with a Member. They coordinate the Member performance review, providing the quality assurance for the process. They meet quarterly, perhaps more frequently, with each Site Supervisor and maintain an open channel of communication regarding Member training, team meetings, and other events.

Role of Site Supervisor

Each Member has a Site Supervisor located at the service delivery site. At some sites, the Site

Supervisor might be assigned to more than one Member. Site Supervisors are expected to complete an online training provided by NACHC prior to the start of the program year, are responsible for approving online timesheet and activity reports on a consistent basis, and have the opportunity to develop a professional relationship with their Members while they are in service. Site Supervisors are expected to oversee all aspects of a Member’s daily experience. They develop the Member’s assignments, coordinate day-to-day activity, monitor and evaluate performance, assist with selection of training, and help with reporting.

Site Supervisors are critical to the overall experience of a Member. One Member indicated “This whole experience would have been terribly different if I did not have a symbiotic relationship with my Supervisor.” Another shared that the best thing about Community HealthCorps is “my fellow Members and awesome Supervisors.” Other Members shared concerns regarding Site Supervisor leadership skills: “I would choose site and program Supervisors with stronger leadership skills….” and overall satisfaction with the Site Supervisor-Member relationship: “I would ensure that each Member is satisfied with their Site Supervisor and daily responsibilities.”

Overall however, based on data from the Member Exit Survey data, Members seemed to be satisfied with “the working relationship with your Site

25


Supervisor”. Their overall satisfaction with their Site Supervisor was high and consistent across sites (3.39 on 1-4 scale, sd=.82, n=406).

In addition to being responsible for Members, Site Supervisors are expected to be knowledgeable about and abide by AmeriCorps and Community HealthCorps policies and procedures, terms and conditions of the Member Contract, and MOA between the Operating Site and the service delivery site.

The program evaluation does not have information about whether Site Supervisor training included relationship model(s) that are available for Site Supervisor consideration or use (such as an apprenticeship model, a mentor model, a protégé model, a supervision model, other). Neither were data available regarding Site Supervisors’ actual interactions with Members.

Members

Who Were the 2011- 2012 Program Members?

There were a total of 481 individuals that were accepted as Members during the 2011-2012 program year. Some had served in the Community HealthCorps or another national service program immediately prior to this year’s service (13%). Some individuals were unemployed before enrolling as a Member (21%), while others left part-time or fulltime employment to participate (42%). While serving in Community HealthCorps, 16% either continued or began part-time employment outside of their Community HealthCorps duties. Prior to joining Community HealthCorps, over half of the Members had been students (51%), and during their service year, 28% of them “took classes through an education institution or program.”

Members had differing levels of education and ranged in age from 18 to 63 with half being 24 years old or younger (average age was 26 years). Age was not a factor in experience or outcomes except for a Member’s satisfaction with the working relationship with peers. The older the Member, the less satisfied they were with their “working relationship with other Community HealthCorps Members”.

However, most Members appreciated the opportunity to interact with other Members and particularly valued the opportunity to “work with such compassionate people from diverse backgrounds.” And even though their backgrounds may have been diverse, Members often found themselves serving with “other like-minded young adults” who together, “grew as friends and were able to complete some major projects that directly improved the overall well-being of the community.” One Member noted that he had “created a bond with my coworkers like no other.”

Figure 11 - Education Level

High School

Certi�cate/Technical

Some College

Associate Degree

Bachelor's Degree

Graduate Study or Degree

High School

Certi�cate/Technical

Some College

Associate Degree

Bachelor's Degree

Graduate Study or Degree

Education Level

n=22

3

45

17

275

34

Education level was found to be negatively related to some experiences and outcomes, suggesting that the higher a Member’s level of education, the lower they rated each of the following:

Perceptions of Overall Quality of Training •and of each core course cluster

Perceptions of Overall Skills Development, •specifically communication, professional behavior, and personal management skills (see next section for definitions)

Satisfaction with support received on •assignments

Many entering Members had intentions to pursue additional education in a health related field (75%) and/or pursue a career in a health field (78%). Many also planned to work in a community-based setting (70%). Most had already volunteered in a community setting (90%).

While the majority of new Members intended to pursue additional education in a health field after completing Community HealthCorps, many entered the program without any or limited health-related training or education. Being able to play an active role in services that in other settings would require a higher level of training was an important aspect

Figure 9 - Members’ Location of Origin

Home State # Members

California 86

New York 72

Massachusetts 35

Michigan 35

Texas 33

Connecticut 25

Washington 24

Colorado 17

Idaho 17

Ohio 13

Maryland 11

Missouri 11

New Jersey 11

Pennsylvania 9

Maine 8

Puerto Rico 8

District of Columbia 7

Wisconsin 7

Louisiana 6

Nebraska 6

Minnesota 5

North Carolina 5

Oregon 5

Virginia 5

Florida 4

Tennessee 3

Alaska 2

Iowa 2

Indiana 2

Wyoming 2

Illinois 1

Kentucky 1

Oklahoma 1

Rhode Island 1

Vermont 1

Members’ Location of Origin

Over half of the members (54%) came from five states: California (18%), New york (15%), Massachusetts (7%), Michigan (7%), and Texas (7%). The home state of the rest of members, however, was one of 28 other states, the District of Columbia, or Puerto Rico. This broad distribution of members’ location of origin reflects a nationwide awareness of and recruitment for the program. See Figure 9.

Member Status

Out of the 481 individuals on which there are data for the 2011-12 program year, 361 were new members who successfully completed the program and another 15 were second-year members. An additional 29 members were still enrolled in the program at the end of the program year. During the year, 43 Members left the program in good standing while another 32 were administratively removed from the program. One individual was suspended at the end of the program year.

Figure 10 - Member Status

Status Number of Members

Second Year 15

Enrolled 29

Exited – Successfully Completed 361

Exited – Without Cause 29

Exited – Compelling Personal Reasons 14

Suspended 1

Exited – Cause 32

Members’ Origin and Status

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of the program for many Members. One Member noted Community HealthCorps’ ability to “give someone without a higher health degree exposure to a health care setting,” while another valued being able “to jump right into working in a community health center setting, even if you do not have much previous experience or education directly related to the health field. It allows you to try new experiences and explore new fields of work and study.”

In addition to serving as a Member in a community health center setting, almost half of the Members (47%) also utilized the services of a community health center themselves. Seventeen percent reported that at least one family member had also used those services.

How Did They Serve Their Communities?

Members served a total of over 800,000 hours during the 2011-2012 program year. Their activities included direct service to clients (683,660 hours), volunteer recruitment and retention (12,380 hours), fundraising (2,103 hours), and participating in individual and team training (73,740 hours). This report highlights direct service, volunteer recruitment and retention, and training.

Direct Service

As illustrated above, Members spent most of their time providing direct service to clients. Dependent upon their assignments, they could have interacted with large numbers of clients or focused their services on a few. The clients could be new to the system or returning.

Each Member had up to four different direct service assignments. Assignments could include case management, community mobilization, health education, interpretation services, outreach services, program development, financial/insurance counseling, or one of many other related activities.

The most frequently performed types of direct service (almost 70% of direct service hours) were:

Service Program Development (159,892 hours)

Outreach Services (95,096 hours)

Health Education/Supportive Counseling (89,652 hours)

Case Management – Facilitation (39,723 hours)

Case Management – Referral (29,606 hours)

Financial Counseling / Eligibility Assistance (29,107 hours)

In addition, Members assisted clients with enrollment in health programs, conducted case management assessment, provided interpretation services, conducted parenting education, provided child care during health appointments, provided transportation for health appointments, assisted with housing issues, conducted employment referrals and counseling, and led physical education activity.

All of these direct service assignments provided Members with what they referred to as “real responsibilities” and “real exposure to what it’s like to work in a community health setting”. For many, this was the most important aspect of the program. Members also valued the variety of duties and jobs they engaged in and like that the program provides, in their words, “the opportunity to…explore many positions within the community health field” including “the administrative side of working in the medical field.”

The Community HealthCorps program is designed to allow for flexibility in how Operating Sites identify and address local issues. This aspect of the program is highly valued by some of the Members, particularly when they are given the “freedom to start new initiatives that [they] thought would develop the program best.” As one Member put it, “it also allows for autonomy in choosing what health education projects you’re interested in enhancing at their clinic, so that you can work to improve something that really interests you.”

Regardless of the services they were providing, this group of Members seemed to connect with the community members they were serving. One Member wrote about “the experience of working closely with the population you serve” while another extoled “the amazing people you meet as a direct service provider and educator.” Another Member emphasized that the “high level of meaningful patient contact” was the best thing about her experience, and that she couldn’t have experienced this “in any other job or program.” One Member summarized the importance of this contact saying, “I feel that I have learned about the experiences and life stories as well as the cultures of many patients at the clinic. Without Community HealthCorps, I do not believe that I would have had


28

this opportunity to expand my worldview.”

Members were involved in many aspects of the lives of community health center clients and potential clients. Through the various direct service activities, Members gained valuable experiences and skills, relevant to both professional and personal growth. The value of Member direct service can be translated to a) dollars saved for the community health care system, b) individual, family, and community gains when uninsured and under-insured individuals begin to participate in their own health care decisions, and c) an improved system of community health care through development of future leaders and workforce by being a Member in the Community HealthCorps.

Recruitment and Utilization of Volunteers

Community HealthCorps Members recruited and coordinated the work of almost 6000 non-AmeriCorps volunteers during the 2011-2012 program year. These volunteers logged in excess of 48,000 hours in assisting health centers and other community-based organizations address health and human needs. Volunteers represented many diverse groups including baby boomers, college-age students, and members of disadvantaged populations.

They were able to see the longer-term outcomes of connecting as a community: “The best thing about [Community] HealthCorps is connecting with members of community and becoming integrated into a network of amazing volunteers.”

And Members understood the importance of service and volunteering: “I was given the experience to help others. I volunteered and also had my children be a part of giving back letting them volunteer as well.”

Training

Member training has been perceived to be an important, multidimensional component of the Community HealthCorps program. In addition to training Members for their current service assignments, Operating Sites are expected to provide applicable professional development opportunities as well. NACHC requires that Members receive at least 12 hours of training and/or development per month, the content and format of which may vary considerably according to

Member assignments and goals.

There are three types of required training for all Members: Pre-Service Orientation, Prescriptions for Success, and service assignment training. The average number of training hours for Members in the 2011-2012 program year was 155 hours (sd=76, n=400). Further examination of the Member’s training focused on the Prescriptions for Success core courses.

Prescriptions for Success Core Courses

The Prescriptions for Success, a set of 10 core courses designed to provide a foundation in community health care, includes the following topics: Health Disparities, Patient Relations, Professional Development, Cultural Sensitivity, Civic Engagement, Health Outreach, Health Education, Disaster Preparedness, Case Management, and Primary Care Environment.

Less than half of the Members reported completing all 10 required courses. Even though Members are expected to complete all Prescriptions for Success core courses during their service year, the average number reported as complete was eight (sd=2.5, n=351); the median was nine, and the mode was 10.


Upon further examination of the number of core courses completed, there was no relationship between how many courses were completed and the total number of clients served, Member perceptions of overall quality of core courses, or Member perceptions of knowledge and skills gained during the Community HealthCorps experience. Neither was there a relationship between core course completion and Member plans to pursue a health-related profession or further education in a health related field.

Members were asked to “rate the training you received in the training series, Prescriptions for Success” (using a 1-5 scale where 1=Very Poor and 5=Very Good). The average score for all courses combined was 4.04 (sd=.73, n=391). Additional analyses showed that perceived quality of training received was predictive of the total number of clients served as well as the total number of new clients served. The following Member comments may help explain why.

Members entering their year of service with limited health profession experience commented on the usefulness of the core training: “I didn’t have to have health knowledge to be a part of [Community] HealthCorps and the Prescriptions were an invaluable asset.”

Another Member commented on the applicability of the training to the assignments: “The training and experience I received was beyond anything I could have dreamed of. It was great to be able to use what I learned to really make a difference in my community.”

In order to determine if certain core courses could be clustered using the “quality of training” score for each course, evaluators used an exploratory factor analysis (Principal Component, Varimax, Kaiser Normalization, 8 iterations) and findings did cluster courses.

New “quality of training” scores were calculated for clusters and then used in further analyses. The following table shows the results of the factor analysis and descriptive statistics for each of the new quality of training variables. Note that Professional Development dropped out of the cluster process.

Figure 12 - Prescriptions for Success Factor Analysis

Factor Name Courses in Cluster Factor Loadings

Average Score

Std Deviation

n=

Health Education

Health EducationHealth OutreachHealth DisparityPatient Relations

.81

.74

.66

.62

4.10 .77 390

Case Management

Case ManagementPrimary Care Environment

.79

.674.03 .85 372

Disaster Preparation

Disaster Preparation

.90 3.77 1.02 349

Cultural Sensitivity

Cultural Sensitivity .74 4.13 .88 388

Civic Engagement

Civic Engagement .79 3.97 .85 365

Analyses were conducted to determine if relationships existed between the new quality of training clusters and Member outcome variables. Results showed positive correlations across all quality of training clusters and all major outcome variables described in the Member Outcomes section.

Other Training

Beyond the Prescriptions for Success, the exact hours and content of training is determined between an individual Member and Site Supervisor. It may include training developed and provided by personnel associated with the service delivery site, shadowing of the Site Supervisor or a medical professional at the service delivery site (up to 40 hours), or independent coursework provided through a third party (up to 10% of total hours).

For Members, the concept of training included individual and team experiences that went beyond knowledge and skill building to encompass a much wider view of growth and development. One Member summarized this perception in writing: “The best thing about Community HealthCorps is the support Members receive, specifically around training and building a sense of community with other Members. Holding PSO before serving at our sites was very helpful to get a sense of the issues we would be facing, and also to forge relationships with other Members.”

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“Perhaps the most affirming experience on the weekend was on my flight home from Omaha...It showed me that the work we do isn’t appreciated by AmeriCorps Alumni and current members alone, but by total strangers as well. People are aware of the work we do and are proud of us. As I boarded the plane, a flight attendant asked me if I was headed home. “Sort of,” I said. “Home, then back to Boston. I’ll be there for a year.” He looked at me quizzically,” What, do you work for the road service or something?” When I told him I was in the AmeriCorps, he was really excited. “you’re those people that run around doing good things, right?” “I guess so,” I replied, “I’m working in a homeless shelter this year.” “Wow, that’s amazing girl,” he said “you keep doing what you’re doing.” During the flight, he pointed me out to the other flight attendants, saying, “This girl right here, she’s in the AmeriCorps.” The others smiled and nodded approvingly, adding “Good for you,” or “Wow.” I spent the rest of the flight feeling a little embarassed and trying to be inconspicuous. I walked by him again as I got off the plane and he patted me on the back and said, “ We’re proud of you guys. you’re doing some great things. you go girl!”

This whole weekend, and especially the reaction I got on the plane ride home, reminded me how great it is to be here and working to make our country a better place. I feel completely re-energized and I have been able to take a step back and look at the big picture. I’m here to do health education, to keep records, and register people in our record system, but most of all I’m here to make things better for a very vulnerable population. I’m incredibly lucky to be doing this, and I hope to effect the people around me in a positive way every day for the rest of my service.”

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Member individual outcomes

(How Their Service Changed Them)In Section III, Description of the Program, the Member logic model illustrates the Member, his or her experiences in Community HealthCorps, and the resulting two outcomes the program is aiming to achieve. Below is an expanded version that proposes the short-term outcomes on which the longer-term outcomes are based. This section provides details regarding those short-term outcomes and any programmatic components found to be related. Most of the data for this section came from the Member Exit Survey completed by Community HealthCorps Members at the end of their service year.

Figure 13 - Expanded Member Logic Model

Health Professional

Personal GrowthCommitment to Service

Operating & Delivery Sites

Training

Member

Delivery Site Supervisor

Direct Service

Client Interaction

Peer Interaction

CHC

Satisfaction with

Participation

Improved Knowledge and Skills

Changed Attitudes

Intentions to

Behave


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Satisfaction with Participation

There are two quantitative indicators taken from the exit survey that represent Member satisfaction with participation in the Community HealthCorps. The first question is: “How satisfied are you with the following aspects of support and recognition?” There is a set of five statements utilizing a response scale with four selections (1=Very Dissatisfied, 2=Dissatisfied, 3=Satisfied, 4=Very Satisfied). Each statement refers to a specific aspect of support. They are listed below in order of highest to lowest average scores for level of satisfaction.

Relationship with Other Community HealthCorps Members (3.56, sd=.60, n=396)

Relationship with Site Supervisor (3.39, sd=.83, n=396)

Guidance from Program Coordinator (3.36, sd=.77, n=396)

Recognition for Good Performance (3.30, sd=.75, n=396

Support for Assignments (3.27, sd=.74, n=396)

When examining interrelationships among these items, both “relationship with supervisor” and “guidance from coordinator” were positively related to “perceived support for assignments” and “recognition for performance.” The pattern of interrelationships may suggest the way in which Site Supervisor and Program Coordinators work together to both 1) support Members as they perform their assignments and, 2) reward good performance.

Figure 14 - Member Interrelationships

Program Coordinator

Supp

ort

Reco

gniti

on o

f Pe

rform

ance

Member Performance of

Assignments

Site Supervisor

Supp

ort

Reco

gniti

on o

f Pe

rform

ance

Further analyses indicated that all five of the satisfaction measures were positively related to other outcome measures (as described below) including the following second measure of satisfaction.

A second measure of satisfaction with participation is represented by Member ratings of core training courses. As described in the previous section, Members gave high marks to required training courses with an “overall quality of training” average score of 4.04 on a five-point scale (sd=.73, n=391).

Broken down into the various core course clusters, average scores from highest to lowest were:

Cultural Sensitivity (4.13, sd=.88, n=388)

Health Education (4.11, sd=.77. n=390)

Case Management (4.04, sd=.85, n=372)

Civic Engagement (3.97, sd=.85, n=365)

Disaster Preparation (3.77, sd=1.02, n=349)


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Further analyses discovered relationships between the quality ratings for each of the core course clusters and other outcomes. These findings are discussed below.

Overall, the data indicate that Members showed high levels of satisfaction with their participation in the Community HealthCorps. This would suggest that the first outcome hurdle, satisfaction with participation, has been cleared.

Knowledge and Skills

In order to capture perceptions of knowledge and skills gained, the exit survey asked Members, “For this first set of skills, please indicate the quality of experience you have gained since enrolling in [Community] HealthCorps.” The list included 14 skills, and the response set was a five-point scale ranging from 1=Very Poor to 5=Very Good. All 14 skills had average scores above 4.0 and the standard deviations indicated reasonably close agreement across Members (all less than .90). A “total skills score” (an average of a Member’s ratings across all 14 skills) had an average of 4.33 (sd=.57, n=393).

In order to determine underlying constructs driving patterns of responses and to place the skills

into meaningful categories, an exploratory factor analysis was conducted (Principal Components Analysis extraction with Varimax Rotation (with Kaiser Normalization). From that analysis, the four clusters of knowledge and skills that emerged are presented in the table below.

Figure 15 - Skills Gained in HealthCorps Factor Analysis

Factor Name Skills in Cluster Factor Loadings

Average Score

Standard Deviation

n=

Communication Listening and respondingCommunicating clearlyConsulting with others

.84

.85

.82

4.35 .65 391

Professional Behavior Leading by guiding and motivatingLearning new ways of thinking/actingAdapting behavior in response to changing situationDealing with uncomfortable situationsBeing reliable

.77

.77

.75

.63

.67

4.30 .62 393

Personal Management Problem-solvingKnowing how to gather and examine information from different sourcesManaging time under pressure

.79

.75

.72

4.21 .66 391

Appreciating Diversity Serving with people from diverse backgroundsServing patients with backgrounds unlike your ownAccepting guidance from others

.75

.85

.67

4.56 .66 392

Each of these knowledge/skills clusters were positively related to satisfaction measures described above.


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Attitudes

The lone quantitative measure concerning attitude was this item on the Member Exit Survey: “Because of serving in the Community HealthCorps, I re-examine my beliefs and attitudes about other people.” The average score for Members (using a five-point agreement response set) was 4.24 (sd=.84, n=396). Though correlations between this item and responses on the satisfaction measures were smaller than they were with quality of knowledge and skills, there were still positive relationships between this item and all other outcomes.

An examination of qualitative data showed how Members, in some cases, experienced major positive shifts in their attitudes toward persons with backgrounds different than their own, community health care, and their understanding of living a life of service. Some Members highly value the “raw interactions [the program] provides with diverse groups of people” and feel the best thing about Community HealthCorps was the “direct contact” and “great experience of working with patients from diverse and disadvantaged backgrounds.” One described how this program brings together “people from different backgrounds for one common goal,” while another wrote about how this experience allowed her “to be more a part of my community and share moments with people I would normally not see every day.”

While many Members come from and are intimately familiar with the types of communities

in which most of the Community Health Centers are located, a good portion of them are not. One Member noted this when he wrote, “the best thing about [Community] HealthCorps is the real-life experiences that provide Members with a glimpse of the struggles faced by a large and increasing percentage of the U.S. population. For many Members, Community HealthCorps provides the first sustained interaction with the underserved community. This consistent interaction provokes a lot more reflection over the meanings of race, gender, and socio-economic status in our society than does a “one-and-done” type of volunteer experience.”

In addition to helping Members “broaden [their] horizons and understand how to work with many different people,” many Members felt Community HealthCorps allowed them to gain “a new perspective about health care.” In their minds, “the unique positions we are able to hold in the community health sector provide amazing insight into how community health functions and how to become involved and improve it.” One felt “the face-to-face experience you gain with health care professionals and patients,” allows Members to understand “the specific needs of all types of populations, and how America’s health care system is and isn’t ready to meet all of these needs.”

This changed perspective on the community health care was one of the most broadly written about topic when Members were asked what they felt was “the


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best thing about [Community] HealthCorps.” Other Member comments on this subject include:

“The best thing about [Community] •HealthCorps is learning about: community health centers and the services they provide; how community health centers are a hub for patients’ health and social services that advocate for patients’ wellbeing; and how to go upstream to advocate and make sustainable changes that improve patients’ health.”

“The best thing about [Community] •HealthCorps is that it can expose the AmeriCorps members to several facets of the health care system. For me at least, I was able to gain a new perspective on public health and the interconnectedness of the issues facing a given community and/or population. That new perspective helped me clarify entry points into health care that might be the best fit for me.”

“The best thing about [Community] •HealthCorps is the opportunity to serve full-time in a community health clinic. This has enabled me to not only observe the many interesting, wonderful, challenging, and frustrating aspects of working in urban community health, but to also gain hands-on experience working to facilitate health care access and quality patient care for many underserved populations. Whereas I once only read about barriers to care or how health policy changes directly affect patients, I have been witness to these matters directly over my time in [Community] HealthCorps.”

“The best thing about [Community] •HealthCorps is helping underrepresented communities engaged in creating benefits for all no matter of race, ethnicity, education, social economic status or other status. Community health care before profit. The idea of true help to those who need it.”

While Members are often placed in challenging settings, these experiences seem to inspire some of them toward even more involvement in the future. One Member commented that “seeing the impact that our service has on the community” and “the gratitude and appreciation from community members encourages and motivates me to continue

in my service.” Another felt the best thing about the program was “the social understanding you develop.” She went on to emphasize that before this program, “I did not understand and therefore was never compelled to play an active role in the community. I now fully intend to; I find myself eager to serve.”

Intentions

The exit survey had a variety of questions that explored the Members’ immediate and longer-term intentions related to employment, further education, more service, and other possibilities.

Results showed that Members were considering many different options. In order of most to least, Members indicated they planned to pursue the following activities: education (73%), fulltime employment (40%), volunteering in their communities (35%), part-time employment (22%), another national service opportunity (6%), and military (2%). Respondents could select more than one option, so the percentages are not mutually exclusive.

Almost 20% of Members indicated their intentions to continue in Community HealthCorps. One Program Coordinator commented that Members “are constantly looking for new ways to make their service as full as possible and many are looking forward to possibly serving another term.”

When asked about their plans to either immediately work or prepare to work in a health-related field, over 30% indicated that they were immediately going to work in a health-related field. Almost 60% indicated that they were going to begin preparation to work in a health-related field. (Because individuals could indicate both immediate and future plans, these percentages are not mutually exclusive.)

The top health-related fields were:

Preparing to work as a physician or surgeon (23%)

Preparing to work or immediately working in social work (10%)

Preparing to work or immediately working in health education (9.5%)

Preparing to work or immediately working in community health (9%)


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Indicators for Long-term Outcomes

When examining the quantitative data for measures of long-term outcomes, the following set of statements appeared to have the best potential for representing long-term outcomes that could be directly attributable to service in the Community HealthCorps:

Because of serving in the Community HealthCorps…

I plan to pursue a career in a health field.•

I plan to pursue further education in a health •field.

I plan to work in a community-based setting.•

I plan to volunteer more than I did before •AmeriCorps.

I re-examine my beliefs and attitudes about •other people.

I take better care of my own health.•

This type of question incorporates both the cause and effect into the response and typically works well when there has been no pre-measure or there is no comparison group.

Members responded to each statement using a five-point Likert scale (1=Strongly Disagree, 5=Strongly Agree). As in other pre-analyses, in order to determine underlying constructs driving patterns of responses, and to place the items into meaningful categories, an exploratory factor analysis was conducted (Principal Components Analysis extraction with Varimax Rotation (with Kaiser Normalization). From that analysis, two factors emerged: one regarding professional intentions and the other about personal intentions.

One Member captured both of these factors when describing the best thing about Community HealthCorps: “it offers an opportunity for transition between school and full time employment while also offering opportunities for professional and personal development.” Another Member described the nature of the program itself and how it related to both personal and professional outcomes: “The program really advocates growth and professional development. Never have I had the privilege and opportunity to be part of a program that encourages collaborations and team building to reach a better/healthier community. It has nurtured and encouraged my curiosity in public health issues and has allowed me to further explore those curiosities and passions, and for that I am very grateful.”

Factor One was related to professional intentions and contained items associated with pursuing health careers, more education in health field, and working in a community setting. When asked what was the best thing about serving in Community HealthCorps, one individual described the professional aspect: “In my opinion one of the best things about [Community] HealthCorps is countless opportunities to develop professionally.” Another described the professional benefits more broadly: “The best thing about [Community] HealthCorps is the ability to learn so much and gain experience that will ultimately benefit you greatly in any career you decide to pursue.”

The second factor was more personal, with items such as volunteering more, examining personal attitudes and beliefs, and attending to one’s own health. One Member explained how “you really learn a TON about yourself that you wouldn’t have learned in any other setting, and you get to change lives, and help others while helping yourself.” Another described the best

Figure 16 - Long-Term Outcomes Factor Analysis

Factor Name Intentions Factor Loadings

Average Score

Standard Deviation

n=

Professional Intentions I plan to pursue a career in a health fieldI plan to pursue further education in a health fieldI plan to work in a community-based setting

.95

.95

.52

4.23 .87 396

Personal Intentions I plan to volunteer more than I did before AmericorpsI re-examine my beliefs and attitudes about other peopleI take better care of my own health

.82

.80

.75

4.09 .75 396


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thing about participating in the Community HealthCorps is having “Una opotunidad para crecer.” (Translated: “An opportunity to grow.”)

Some Members readily link their personal and professional experiences in the program. One Member reflected that the best thing about Community HealthCorps is “the opportunities to become a better you. Through [Community] HealthCorps you can grow both professionally and personally. I have matured and now can make an educated decision about my future career path and learned how to properly take care of myself health-wise,” while another praised Community HealthCorps for the “personal growth that takes place during your service year; “I have become a much more empathetic and compassionate person as a result of my service, characteristics that will help me greatly in the future as a health care professional.”

The Member Exit Survey also asked respondents to indicate their level of agreement with the first four statements above from a retrospective context: “Before serving in the Community HealthCorps…” In order to determine if individuals that entered the program with high pre-program intentions were different (on their post-program intentions) from those who had lower pre-program intentions, respondents to the exit survey were divided into two groups based on “no to low” and “medium to high” pre-program intentions.

As expected, those that entered Community HealthCorps intending to pursue careers and education in health fields scored higher on professional intentions but similar on personal intentions. Perhaps the more important findings are related to changes in Professional Intentions within those two groups. The table (Figure 17) illustrates that the Community HealthCorps had a positive impact on professional intentions for those entering with low professional intentions but no impact at all on those entering with high intentions.

To determine the best predictors of professional intentions and personal intentions, a stepwise multiple regression was conducted on each. Satisfaction with Support and Rewards, Quality of Training, and Quality of Knowledge and Skills

outcome variables were included in the analyses. Entry into the model was set at .05 and exit at .10.

Three variables were identified in the set of best predictors of professional intentions related to community-based health care. Two were knowledge and skills-related and one was quality of training-related. Presented in order of most to least amount of unique variance, they are:

Quality of Professional Behavior Skills 1. (Leading by guiding and motivating, Learning new ways of thinking/acting, Adapting behavior in response to changing situation, Dealing with uncomfortable situations, Being reliable)

Quality of Appreciating Diversity Skills 2. (Serving with people from diverse backgrounds, Serving patients with backgrounds unlike your own, Accepting guidance from others)

Quality of Health Education Training 3. (Health Education, Health Outreach, Health Disparity, Patient Relations)

There were two variables that best explained Members’ personal intentions, one was knowledge and skills-related and one was quality of training-related. In order of most unique variance explained, they are:

Quality of Professional Behavior Skills 1. (Leading by guiding and motivating, Learning new ways of thinking/acting, Adapting behavior in response to changing situation, Dealing with uncomfortable situations, Being reliable)

Quality of Civic Engagement Training2.

Figure 17 - Members’ Professional Intentions

Group (by Score on Pre-Intent - Professional)

Pre-Intent Professional

Pre-IntentPersonal [no data]

Post-IntentProfessional

Post-IntentPersonal

Group: LOW [Score of 1-3] n=56

2.51 (sd=.48) N/A 3.38 (.99) 4.00(sd=.80)

Group: HIGH [Score of 3.01-5] n=340

4.41 (sd=.55) N/A 4.40 (sd=.76) 4.10(sd=.74)

TOTAL N=396 4.15 (sd=.86) N/A 4.23 (sd=.87) 4.09(sd=.75)


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Member-related Client and Community outcomes

(How Their Service Changed Clients and Their Community)Qualitative data analyzed during the evaluation gave credence to the blend of a national and community service model and community health care approach to extend access to health care. Several elements identified in the empirical research were present in the Community HealthCorps Program and were found to help create conditions for success.

Trusting Relationship

Research shows that “The underserved are more likely to continue their care and use referrals for other needed services if they develop a trusting and nonjudgmental relationship with those working at the Health Centers.” (10)

The program intentionally seeks individuals to serve as Members who are members of the local community in which they will serve. They possess similar background characteristics and experiences to their clients. Many Members have been uninsured, unemployed, and have faced many of the same difficult health care decisions as their clients. They are able to use their own experiences and similarities of background to create a trusting relationship with the client or potential client.

Members understand the necessity (and benefits) of creating that type of relationship with clients. One person described the best thing about Community HealthCorps as relationship building: “The people we help in our everyday setting are there to let us know how much of a help we have been to them. We sort of build a relationship with these people, a sort of bond that can’t be broken.”

Another related that being in the Community HealthCorps has helped with integrating into community: “I have been able to be more a part of my community and share moments with people I would normally not see every day. Another great thing is the networking and receiving connections to job opportunities, events and volunteering [right in my own community].”

Even when Members may not initially be a part of the community in which they work, they gain valuable insights into relationship building and

developing empathy: “The best thing about [Community] HealthCorps was helping out the community. It opened my eyes on how other families really struggle to get by in life. So I’m glad we got to help them and was a part of their life.”

“The first time I saw one of my patients on the street and heard her call out my name

excited to see me made me feel a part of the

community and realize what kind of impact I was having in her life personally, but also in the larger community

as well.”[Jemima King, Member]

Health Education

According to a number of studies, individuals without health insurance tend to have less knowledge and understanding about chronic illnesses, the symptoms and how to manage individual care. (2, 9, 15, 16) However, becoming educated about the system and access to it can positively influence health outcomes. (2, 9, 15, 16)

For the 2011-2012 program year, Members spent almost 90,000 hours conducting health education with clients. Furthermore, Health Educator was one of the top four health-related professions Members intend to pursue.

Members see the results of their health education efforts. One Member acknowledged this when


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stating “I had the opportunity to provide health education to many WIC clients whom I felt truly valued the nutrition information. I also was able to build strong and professional relationships with my program director, fellow [Community] HealthCorps Members, and WIC nutrition staff.”

Program Coordinators also recognize the value of health education and appreciate the interest, knowledge, and skill of Members as health educators as evidenced by the following:

“BHCHP Tobacco Cessation •Initiative has grown and been very successful. We’ve been able to get free advanced training for our group; [Members] run cessation groups and offer individual counseling at multiple sites; and [Members] ran two Butt Out health fairs and hosted a collaborative meeting between other local service providers for resource sharing. While true ‘successes’ amongst patients in terms of quitting are infrequent and complex, we have multiple great stories of patients quitting, cutting back, or contemplating!” [Program Coordinator]

“150 unduplicated patients accurately •enrolled in health services and health benefits programs such as; smile builders, diabetes collaborative, access to specialty care and smoking cessation at midpoint of the service year. [Members] are continuing to enroll patients in health services and health benefits programs at a steady pace and will continue to do so for the rest of the program year.” [Program Coordinator]

Simplifying the System

Much of what Members do is related to increasing access to community health care by eliminating impenetrable barriers for clients. Those barriers can be real or perceived but either makes it very difficult for individuals to enter and make their way through a health care system without a variety of kinds of assistance.

Barriers include language, literacy, and preconceived ideas of and prior experience with health care, or more generally, systems “of assistance”. Others are unable to participate because of family obligations, transportation issues, or simply a lack of understanding of their specific health issues and how they relate to other life conditions. Real or perceived financial barriers are a major reason why uninsured or underinsured individuals do not attempt to participate in regular health care maintenance, health education, and the ongoing treatment of chronic illnesses.

Identifying real and perceived barriers and then developing and implementing solutions is a major challenge for overstressed community health care providers. Community HealthCorps Members spend time, energy, and creativity assessing needs and generating and implementing solutions that otherwise would not occur.

A Program Coordinator shared one example of how Members identified a need and addressed it: “Members have assisted in identifying that the patient reminder process needed to be changed to decrease ‘no show’ rates at the health center.” Members spent almost 160,000 hours working on direct service redesign and program improvement and development.


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Expanding Services

Increasing access to community health care can be achieved by expanding the breadth and depth of services. With limited financial resources and the increasing pressure to provide access, community health care providers welcome the opportunity to have national and community service members that can serve a multiplicity of needs emerging within community health care.

One Program Coordinator summed up the contributions of Members to the clients and community: “One of the great successes of this program year has been amazing service projects that Members have planned and held. The group has been extremely motivated to develop, plan and implement service projects that serve a large amount of individuals and really enhance the health and wellness of our patients and the communities we serve. Their dedication and hard work brings such vitality to our communities.”

Not only do Community HealthCorps Members provide many different direct services to clients

and potential clients, but they also work to facilitate partnerships and collaborations with outside agencies and recruit additional volunteers. (5, 9) Community health care organizations recognize the value of having national and community service members at their sites. One prior survey revealed that 93% of organizations with Community HealthCorps Members believed that having these Members allowed service to additional individuals in the community. (5)

The flexibility of Member assignments and training options as well as the on-site direction and support provided by Site Supervisors creates an ideal atmosphere for problem solving. With the freedom to create and experiment with solutions while under the guidance of supervising health professionals, Community HealthCorps Members gain valuable real-life experience in enhancing community health care systems.


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VI. Summary Findings and RecommendationsThis section contains summary findings associated with each of the program components: Program Central Administration and Leadership, Sub-grantees and Outreach Sites, Members, Member Individual Outcomes, and Member-related Client and Community Outcomes. One or more recommendations are offered for each summary finding.

Note that there are many more findings throughout Section V that readers will want to examine more closely and at length. This section has selected those findings that were most salient throughout the conduct of the evaluation.

Program Central Administration and Leadership

1. The evaluation did not include gathering extensive information from or about the central program management and leadership within its scope, but instead focused on the local Operating Sites and Members. However, literature does support a decentralized approach to program management when the overall success of the program depends upon a flexible framework assuring consistency without major constraints in the implementation or management of day-to-day activities.

• Aquestionforfutureconsideration:What

might be the exact structure for successfully employing multiple levels of program management (national, sub-grantee, outreach site) so that a purposefully selected set of principles support a clearly articulated framework that has the right amount of flexibility, consistency, and accountability?

2. With a decentralized approach to program management, central mechanisms for assessment, monitoring and accountability must be carefully constructed and consistently applied. The Operating Site Risk Assessment process and instrument did not produce much variance across sites for the program year in question (2011-2012). The average total risk was 5 (out of 35) and the standard deviation of 2.6 suggests that 95% of the sites will fall under a score of 10. This type of assessment should possess a high level of discrimination and when used across a typical set of programs, should place those programs into categories of risk with maximum variance between and not within categories. If there is little possibility the process will produce the full spectrum of scores from the instrument, then a recalibration of the instrument and process is needed. Despite this limitation, Operating Sites were classified in each of the three risk classifications (high, moderate, low) during the 2011-12 program year.

• CommunityHealthCorpsshouldworkwithexperts to re-conceptualize and redesign the Operating Site Risk Assessment Process


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and Instrument.

Operating Sites and Service Delivery Sites

1. There is tremendous diversity across and within sub-grantees that produces a rich selection of living laboratories for Community HealthCorps Members. It was difficult to find information about the sub-grantees, however, that would help explain or predict which local programs may require assistance, remediation training, or just extra attention. One purpose of evaluation is to identify a set of metrics that represent the program’s inputs, activities, outputs, and outcomes. The metrics should be grounded in program theory and when used in a formative process, they should be able to connect program elements and identify areas of concern. The evaluation really did not identify important characteristics of the local program that would predict its success. Several variables were hypothesized to relate to Total Risk Score (number and geographic spread of outreach sites, years in the program, for example) but there were no significant findings. This may be due to the lack of variance produced in the set of Risk scores.

• CommunityHealthCorpsshouldcontinueto examine and address critical differences among sub-grantees that relate to the overall success of the local program.

2. The evaluation could uncover no information about the model(s) promoted or used to establish the relationship between the Member and Site Supervisor.

• Anumberofmodelscouldbeemployedincluding the apprenticeship model, the mentor model, or the Site Supervisor-employee model. Community HealthCorps should select one or more models and provide basic information and training on the selection(s).

3. Literature suggests that community-based assistance programs are more successful at client recruitment and retention when they are part of a local, multi-service collaboration. The application process for sub-grantees requires information about collaborative efforts but lacks details on whether there are actual collaborative partnerships or just cooperative arrangements.

• Currentresearchsuggeststhatcollaboration is a critical component of successful community health care systems. Community HealthCorps should examine the various types of collaboration configurations that are currently in place across sub-grantees and incorporate any important findings into the application and selection process.

• CommunityHealthCorpsmaywanttofurther investigate well-known models of collaboration (Wilder Collaboration Factors, for example) and consider creating training modules for sub-grantees.

4. Most Program Coordinators are responsible for multiple service delivery sites with multiple Members at each. Many sub-grantees have service delivery sites that are an hour or more away from the Program Coordinator location and/or other service delivery sites. This situation may place extra burden on the Site Supervisor as well as increase the potential for Members at geographically dispersed service delivery sites to feel less connected to the Community HealthCorps as a national service program.

• CommunityHealthCorpsshouldlookmore closely at the potential impact of geographic spread of sub-grantee service delivery sites on local programs and Members. Potential issues should be discussed with Program Coordinators, Site Supervisors, and Members using a collaborative process. Any potential or real issues discovered should be addressed though cooperative problem solving approaches. Measures should be put in place to determine the success of any solutions.

Members

1. Members varied in age, education level, and most other demographics. These differences did provide some insight into how Members’ experiences and outcomes can differ based upon their unique personological profiles. However, in order to maximize the Community HealthCorps experience for every Member, demographics are not the only individual differences that should be considered. For example, a major influencing factor in out-


43


going Members’ intentions to pursue heath-related careers was the level of intentions as they entered the program. The group with the lowest intentions coming into their service year was the group with the lowest intentions as they exited. However, they were also the group whose intentions increased as a result of their participation in Community HealthCorps. Those who had high levels of intentions related to the health professions at the beginning of the service year had the same level of intentions at the end of the service year. The lack of an increase from before to after the program for the Members with high intentions initially may be due to a statistical phenomenon, regression to the mean, or the fact that pre-intentions were measured retrospectively and could have been inflated. However, this finding is important and should be examined further through interviews and other methods.

• CommunityHealthCorpsshouldgathermore specific information from and about Members at the beginning of their service year and, using results from this evaluation, develop specialized experiences and/or training modules based upon key individual differences. Certain demographic groups of Members should be more closely followed throughout the program year so that intervention strategies can be implemented, in real time. Selected alumni and current Members as well as Program Coordinators and Site Supervisors should be involved in this entire process.

• Usingresultsfromthisevaluationandadditional data-gathering processes, training and resources should be developed for Program Coordinators and Site Supervisors. These resources could be in the form of case studies that illustrate Members with different demographic characteristics (educational levels, for example) and how experiences and training can be augmented or changed for certain groups.

2. Members had differing amounts and types of training experiences. They were encouraged to work with Site Supervisors to determine specific needs they may have that could be addressed with unique types of training content and methods. Information on all the various types

of training in which Members participated was not available. However, when examining the total amount of time each Member spent in training and the number of core courses they reported as complete, there was no relationship between these indicators and Member outcomes. Their perceptions of the quality of the core courses were, however, positively related to and predictive of various outcomes including satisfaction with components of supervision and rewards, knowledge and skills gained, attitudes toward clients, and intentions to pursue health and community-related careers and education.

• Asimportantasitistotracktimespent(daily or weekly) on different types of activities (direct service, training, fundraising, volunteer recruitment), it is just as important to gather Member reactions to their activities in real time. Being aware of and addressing satisfaction with training and other components of the program at “the moment of occurrence” can: intervene in a downward slide of Member affect toward the program, enhance their service experiences, and increase the probability of positive outcomes. Community HealthCorps should implement a system of gathering relevant information from Members throughout their service year and use that information in a “just-in-time” type of intervention (communication with Operating Sites, training/resources, other).

3. Findings illustrated the way in which Prescriptions for Success core courses clustered based upon Members’ perceived quality of each core course. Three courses did not cluster with any others (Disaster Preparation, Cultural Sensitivity, and Civic Engagement) and one dropped out of the analysis (Professional Development).

• Amorethoroughevaluationofeachcorecourse should be conducted. Community HealthCorps should examine the courses within each cluster for similarities in basic content, methods of instruction, Member appeal, target skills, setting for application, immediacy of need, or other potential underlying factors that might explain why those courses were grouped together by


44


Member responses on the Exit Survey. And similarly, those courses that did not cluster should be examined for differences in these factors.

4. Members were involved in the recruitment and management of non-Community HealthCorps volunteers. Volunteer programs typically focus on service and provide specific ways for individuals and groups to “give back” to their communities. Involving national service program members in another type of service program (community volunteers) maximizes the opportunity for personal growth and enhanced commitment to community and service.

• CommunityHealthCorpsshouldcontinuean emphasis on combining the National Service model of the Member with the community-based volunteer model in order to maximize achievement of both of the long-term outcomes for the program: increased access to community health care and workforce development for Health-related professions.

Member Individual Outcomes

1. Member outcome measures included two categories of satisfaction, four knowledge and skills factors, an attitude measure, and multiple types of intentions including two long-term indicators of intentions, professional intentions and personal intentions. All outcomes had average scores that were on the positive range of either a four-point or five-point scale. Responses across Members were similar as represented by reasonable standard deviations (less than 1.0 on 5-point scale).

• Thesefindingsindicatethatoverall,the Community HealthCorps program is successful as a National Service Organization.

2. Each set of outcome variables was related to and predictive of the next set (as illustrated in the Member logic model). Satisfaction variables predicted Knowledge and Skills and Attitude; In turn, Knowledge and Skills and Attitude predicted Intentions. These relationships illustrate the importance of attending to each component in a Member’s experience using methods and approaches that allow for

assessment, remediation, improvement, and monitoring.

• CommunityHealthCorpsshouldfacilitate the implementation of a system of monitoring and feedback that local Operating Sites and service delivery sites can use that connects to all components of a Member’s experience.

• CommunityHealthCorpsmaywanttoconsider formally adopting a theory of behavior that explicates these outcomes and their relationships to each other and to future behavior. Two possibilities are the Theory of Planned Behavior and the Theory of Reasoned Action.

3. Two long-term outcome measures were created using Exit Survey data: Professional Intentions (plan to pursue a career in a health field, plan to pursue further education in a health field, plan to work in a community-based setting) and Personal Intentions (plan to volunteer more, re-examine my beliefs and attitudes about other people, take better care of my own health). Members scored high on both types of intentions.

• Anumberoffactorswererelatedtopersonal and professional intentions. Community HealthCorps should further examine the evaluation findings to determine areas that are of particular concern or interest and build on successful components and address any issues.

4. Knowledge and skills outcomes were found to be important predictors of professional and personal intentions. Of the four clusters of knowledge and skills, Professional Behavior was the best predictor for both professional and personal intentions and Appreciating Diversity was in the set of (three) best predictors for professional intentions. The exact wording from the Exit Survey measures for knowledge and skills relates to “the quality of experience gained since enrolling in [Community] HealthCorps”. The wording would suggest that Members’ responses contained some amount of reflection on experiences that specifically provided them with an opportunity to learn and/or use those knowledge and skills.

• CommunityHealthCorpsshouldinvestigate


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further the types of experiences that provide Members the knowledge and skills related to: Professional Behaviors (leading by guiding and motivating, learning new ways of thinking/acting, adapting behavior in response to changing situation, dealing with uncomfortable situations, and being reliable), Appreciating Diversity (serving with people from diverse backgrounds, serving patients with backgrounds unlike your own, accepting guidance from others)

Member-related Client and Community Outcomes

1. Because there are currently no client data regarding perceptions, knowledge, skills, attitudes, intentions, behavior, and conditions (health, family, economic), the evaluation has used prior research and program theory to connect Member outcomes to client, community, and health profession outcomes and impact.

• Basedontheprogram’stheoryandlogicmodel, the evaluation findings conclude that Member Outcomes should predict client outcomes. They should also predict health profession outcomes. If empirical research continues to support the remaining theory that connects client outcomes to family and community outcomes and impact, then the Community HealthCorps Program is well positioned to realize long-term impacts in the future.

VII. Evaluation Process Findings and Recommendations

1. This evaluation relied on programmatic data gathered as a regular course of program management. Quantitative data resided in many different types of data bases dependent upon the particular purpose and use of the data for program management. As mentioned, thirteen different databases were used to create

the data set for the quantitative portion of this evaluation.

• Goingforward,CommunityHealthCorpsshould construct a separate database for program evaluation data that can be used in both formative and summative evaluation processes.

2. No client data were available beyond numbers served.

• Forfutureevaluations,clientinformationshould be gathered. That information should be gathered at an individual client level and include demographic and participation data as well as perceptions, knowledge and skills, behavior choices, and actual health condition (if possible).

• Futureevaluationsmustgatherdatathatillustrate the interrelationships of Member as both beneficiary and benefactor in the Community HealthCorps model. With addition of client data to the evaluation, this should be possible.

3. This evaluation process did not use a full stakeholder approach. It was determined that the process and results would be focused for a select group of stakeholders.

• Futureevaluationsshouldbestakeholder-based and involve a representative group of major stakeholders in the design, implementation, data analysis and interpretation of results.

4. This evaluation did not use a collaborative approach.

• Futureevaluationsshouldemploya collaborative approach to design, implementation, monitoring and utilization of results. Community HealthCorps alumni, current Members, Program Coordinators, Site Supervisors and central administration should all be involved.


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Promoting Health Care for America’s Underserved

Developing Tomorrow’s Health Care Workforce

What is Community HealthCorps?

Founded in 1995 by the National Association of Community Health Centers, Community HealthCorps is the largest health-focused, national AmeriCorps program that promotes health care for America’s underserved, while developing tomorrow’s health care workforce. The mission is to improve health care access and enhance workforce development through community health center sponsored AmeriCorps including VISTA (Volunteers in Service to America), and related programs. Overarching goals to address the needs of medically underserved and other vulnerable populations served by community health centers are as follows: Increase access to and utilization of primary and preventive health care. Improve the capacity of health centers to provide quality and preventive primary health care services. Foster collaborative partnerships that ensure continuity and sustainability of programs and services. Encourage Community HealthCorps Members to pursue further education and careers in community health

through mentorship and experiential learning. Create a culture of civic engagement and volunteerism to strengthen preventive and primary health care. Community HealthCorps program sponsors are primarily community health centers (CHCs) and primary care associations (PCAs) that host one or more teams of HealthCorps Members. Operating since 2001, Community HealthCorps*VISTA is comprised of project stations (sponsors) - predominantly CHCs, PCAs and hospitals that typically host one or two VISTA Members. Most Members enroll for a full year of service, and many serve for two terms of service. Nearly 500 Community HealthCorps Members currently serve through 35 main health center sites (which include over 350 individual member placement sites) and three affiliate organizations in 18 states, the District of Columbia and Puerto Rico. Members Reflect and Work in Underserved Communities

Members serve rural and racially/culturally diverse urban communities and suburban, as well as migrant farm worker, homeless and public housing populations. Members are as racially, ethnically and economically diverse as the communities they serve. Educational attainment varies from high school and some college to graduate degrees. In addition, some Members are active or retired health and social service professionals. No matter their background, Members become part of a community’s struggle for better health and economic independence.

CHC Impact Eval 2013

Documents